Frontotemporal dementia as underlying cause of newly altered mental status in a 59-year-old female: a case presentation and literature review

Abstract

59 y.o. female is evaluated for chronic behavioral abnormalities. We describe the diagnostic approach to cases of altered mental status. Before considering the different possible etiologies including, for example, metabolic, infectious, toxic, hypoxemic, endocrine, or iatrogenic ones, we underline the importance of assessing patient's baseline functional status. Often, in particular in older patients' population, dementia is the underlying culprit of mentation abnormalities. Through extensive history and with the help of neuroimaging studies, our patient was diagnosed with frontotemporal dementia. ARTICLE HISTORY 1. Case presentation We present the case of a 59-year-old female former psychiatric social worker with past medical history of poorly controlled hypertension, who was brought to the emergency room by her family for acute on chronic behavioral abnormalities. Before coming to the emergency department, the patient had been driving in circles for 3 hours and was agitated. Her family reported that over the last year and a half, the patient's mental status had been deteriorating. She had progressive memory loss to the point where she no longer remembered details that were mentioned to her 5 minutes prior. She had also become more aggressive over the past few weeks and had been harassing her coworkers to the point where she was suspended from work. Most recently, she could only sleep 2 hours per night. She had no neurological deficits as far as her ability to speak, eat, or ambulate. According to her family, at home, her systolic blood pressure was often above 200 mmHg with diastolic blood pressure up to 130-140 mmHg. She had established care with a new primary care physician 3 weeks prior to presentation. At that time, the patient was started on metoprolol but was not compliant in taking her antihypertensive medication. On admission to the emergency department, the patient was afebrile, blood pressure was 200/ 116 mmHg, with heart rate of 70 bpm, and O2 saturation of 97% on room air. On physical examination , the patient was anxious and fidgety but was otherwise alert and oriented. She had intact cranial nerves II-XII, preserved motor function and sensation bilaterally and no focal neurological deficits. Her head, neck, lung, heart, abdominal, extremities, and skin examinations were unremarkable. Workup in the emergency department included complete blood count, basic metabolic panel, urine toxicology screen, cardiac markers, EKG, and head CT. The complete blood count was normal and basic metabolic panel unremarkable. The urine toxicology was negative. The high sensitivity Troponin T value was less than 6 ng/mL and EKG showed normal sinus rhythm with no acute ST changes or other abnormalities. A head CT was performed and was significant for extensive age-related brain involutional changes with findings of chronic microvascular ischemic disease. In the ED, in order to control her blood pressure, the patient was treated with intravenous amlodipine and labeta-lol. Her agitation improved with the administration of lorazepam but did not completely resolve. The patient was admitted to the hospital to better assess the etiology of her agitation and personality changes. Because of patient's strong family history of vas-cular dementia and her underlying history of uncontrolled hypertension, vascular dementia was initially considered a likely cause of her behavioral abnormalities. However, other potential causes of rapidly progressive dementia were taken into consideration as well including neurosyphilis, Wilson's disease, vitamin deficiencies, endocrinopathies, paraneoplas-tic syndromes, and CNS infections. Thyroid function, anti-TPO and antithyroglobulin antibody were checked and revealed to be unremark-able (TSH value was 2.7 uIU/mL). ESR, CRP, RPR, paraneoplastic antibody panel, serum copper, and ceruloplasmin, vitamin B12, folate, and homocysteine CONTACT A. Coraini